Why We Talk About the Therapeutic Relationship in ISTDP

Are ISTDP therapists self-important, or is there a really good reason we invite you to talk about our relationship with you during therapy? Can talking about our relationship be a useful or even necessary part of your healing process?

Let’s talk it out!

How Attachment History Impacts the Therapeutic Relationship

From the therapist’s first words—“What issues do you want me to help you with?”—therapy begins to involve elements of attachment and interdependency. Implied in this initial inquiry are a series of deeper attachment-oriented questions: “Are you willing to depend on me for some help? Are you willing to let me get close enough that I can really help you with this? Can we combine our efforts and care to do something positive for you?” This invitation to connect and depend in the first moment of therapy may stir up feelings, fears, and interpersonal patterns we first experienced in our early attachment and interdependency relationships with caregivers, siblings, and other significant people.

Our response to that first invitation says a lot about our attachment history: Do we get anxious, tense up, or have trouble responding? Do we avoid answering or offer small talk? Do we get right down to business and allow ourselves to open up and work hard in therapy? How we respond to our therapists’ efforts to offer us an attachment is usually representative of how we respond in our relationships with friends, partners, and children and is also indicative of the ways we learned to navigate attachment to our childhood caregivers.

Why This Matters for Your Therapy

Many people come to therapy due to interpersonal problems, e.g., getting anxious around intimacy, perhaps distancing and detaching from closeness or conflict with spouses or children. As the emotional intensity and intimacy of therapy builds, those same relationship patterns that bring a person to therapy in the first place can begin to emerge within the therapy. This is what psychodynamic therapists call “transference”: the patterns of attachment we learned in childhood begin to show up in our present relationships and therapy. The old feelings and style of relating “transfer” into the new relationship (e.g., Abbass, 2015).

While this transferring of old patterns can sabotage our relationships outside of therapy, the transference process during therapy presents an opportunity to examine, learn from, and even overcome these interpersonal patterns. How do therapists who practice intensive short-term dynamic psychotherapy (ISTDP) help us do this?

‘What Feelings Are Coming Up Toward Me?’

If the transferring of old attachment patterns into new relationships can be destructive to our work and intimate relationships, how do ISTDP therapists leverage this potentially problematic process into a healing experience?

The therapist’s first task is to help you become aware of the attachment dynamics getting stirred up in the therapeutic relationship:

“Do you notice how you’re starting to avoid my eyes? Also, you seem to be withdrawing into your thoughts, talking less. Is there sort of a wall going up between us?”

Then our job is to help you figure out what triggered this detaching attachment response:

“What reactions are you having toward me that make you start to wall up here with me? What emotions are stirred up here toward me that you might be pulling away from?”

Once we clarify the emotional reactions triggering a detached (or anxious) attachment response, we are in a position to help people face and experience the anxiety-provoking emotions and memories they avoid by pulling away from (or fearing) the therapist and others. This process often sheds light on the developmental origins of the interpersonal patterns of anxiety and avoidance bringing people to therapy in the first place.

The Adaptive Function of Transference

This process of accessing and gaining comfort with relationship-oriented thoughts, feelings, and behaviors in therapy increases our ease in dealing with the feelings and memories triggered in us at work and at home. Though transference can be inconvenient in our day-to-day lives, the transference process in therapy is incredibly adaptive—it provides an opportunity to gain perspective on ourselves, the ways we relate to others, and the developmental roots of our interpersonal emotional tendencies.

Transference strikes me as a form of unconscious trust, in which people in therapy show their difficulties to the therapist rather than simply tell them. This gives us a second chance to learn from and overcome the childhood coping patterns holding us back from more satisfying, adult solutions.

Data on the Importance of Transference Work

Case series data from the ISTDP literature by Dr. Allan Abbass (2002) suggest most people who come to therapy will require some work “in the transference” if their treatment is to be effective.

If a therapy does not address problematic relational dynamics in the transference, the risk is high those dynamics will persist. This can render your therapy less effective and allow the problems that brought you to therapy to persist and possibly render the therapy useless.

According to his published case series data, less than 5% of the 342 people seen over the course of six years were “low resistant,” meaning they come to therapy without severely dysregulated anxiety and without significant barriers to emotional closeness with the therapist. “Low resistant” people are able to freely access emotions and obtain insights with minimal support and encouragement from the therapist (Abbass, 2015). This finding suggests a remarkably slim percentage of private practice referrals will not require work in some aspect of the therapeutic relationship in order to experience relief and change.

On the other hand, about 24.5% of the sample became highly anxious (e.g., disruption of cognitive/perceptual functions) in response to the relationship with the therapist. Per Abbass’ (2015) description of his ISTDP approach, people in this “fragile spectrum” require work in the transference relationship in order to build the anxiety tolerance necessary to make good use of the therapy.

Perhaps most strikingly, 57.8% of Abbass’ sample were in the spectrum of “moderately resistant” to “highly resistant,” meaning that at some point in the therapy they would erect interpersonal barriers against closeness and collaboration with the therapist. For people who present with this “transference resistance,” work on the treatment relationship is necessary for the therapy to be effective.

In summary, Abbass (2002) found 95% of the people he saw in this six-year case series required some work in the transference relationship. The case series (2002) suggests clinical and cost effectiveness of Abbass’ approach to ISTDP, which seems to underscore the necessity of some focus on the therapeutic relationship.

What Could Happen If We Avoid Talking About Our Relationship?

What happens if I approach our relationship in a detached way and we never talk about it? Will our relationship stay in a detached state? Will we ever overcome my difficulties attaching if we never confront my detachment?

How about if I’m constantly overwhelmed with anxiety when we’re together, and we go on and on without addressing that? Will we ever get to the bottom of what’s making me anxious in our relationship? Will we ever get to feel good together and connect comfortably?

If a therapy does not address problematic relational dynamics in the transference, the risk is high those dynamics will persist. This can render your therapy less effective and allow the problems that brought you to therapy to persist and possibly render the therapy useless. This is why ISTDP therapists typically focus on our relationship with the people who come to us for help—so we can use our relationship as a healing opportunity where people can overcome problematic relationship patterns rather than perpetuate them.

References:

Abbass, A. (2002). Office based research in ISTDP: Data from the first 6 years of practice. Ad Hoc Bulletin of Short-term Dynamic Psychotherapy, 6, 5-14.

The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the preceding article can be directed to the author or posted as a comment below.

Maury Joseph, Psy.D.

April 11th, 2016 at
11:37 AM

Thanks, Paul. The relationship between therapist and client is only addressed if it is directly relevant to the difficulties that brought the person to therapy. That is not always the case. Also, sometimes people come to therapy with a particular reason for being there, and other areas of difficulty become revealed in the process that we could never have predicted initially.

Sarna

April 11th, 2016 at
3:46 PM

In some ways this makes me think that if someone is this worried about all of that, it’s like they are afraid that the attention is not on them and therefore that is off putting to them… and so they need some therapy!

Reesa M

Maury Joseph, Psy.D.

April 13th, 2016 at
6:16 AM

Cool insight, Paul!
Sarna, it is entirely possible for therapists to misuse the ideas I described in the service of getting attention for themselves, building their self-esteem, and other potentially therapy-destructive reasons. Ideally, though, we only focus on the therapy relationship when it is in the service of helping the client get their needs met. Hope that makes sense!
Reesa, I totally agree!

Louisa

April 13th, 2016 at
11:38 AM

If you are there for a certain reason, like let’s say you always build up these barriers between you and the people in your life that you don’t need to do that with, even if your therapist is a key part of your life I can see how when things get a little uncomfortable in your sessions that there might then be the tendency for you to start putting up those walls with them too. You might know that this won’t do you any good and will actually keep you from getting the most out of being there but the temptation is so great that it can be hard to stop yourself.

Maury Joseph, Psy.D.

April 18th, 2016 at
6:17 AM

Thank you for your thoughts, Louisa. That pattern of walling up is very tempting, and if we look at Abbass’ research, quite common. That’s why I so value the systematic approach to working with those tendencies that I’ve learned from ISTDP (and psychoanalysis). Other therapy models tend not to emphasize that aspect of human relationships.

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